Laserfiche WebLink
Please print of type.(Form designed for use on elite(f 2-pitch)typawritec) Form Approved.OMB No.2050-0039 <br /> UNIFORM NATARUOUS I,Generator lD hbrtebeI 2.Page f of 3 Emergency Response Phorre 4.Manlfesi hacking Humber <br /> wA&TQ h(ANIFt ST .; , ,: : , >{011 A 0 01181912 7 JJK' <br /> 5:Generator's Name and MaErQAddtess Generalols Site Address(Adiffefenl than ma#ng add(ess) <br /> la 3r0 H.MA IN S r 11-30 N MAP) ;3 <br /> GeneratoesPhone: '�t "13'.)oC147'.i <br /> 6.Transporter I Company Name U,S.EPA ID Number <br /> A 0:) 1 '7' 7 O ti <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated FacTity Name and Silo Address U.S.EPA ID Nwrkr <br /> 1)'r'c�Jtk<)I•� <br /> OWN C, <br /> Face sPtone: r7 ).')ill^.a?;)0 l; t �� i!�0'} <br /> ga. 9b.U.S.DOT Description(indud)rg Proper Sfsppng Name,Hazard Class.b Number, 10.Contalners 11.Total 12.Unit 13.Waste Codes <br /> HM and Pac*Q Group(if any)) No. Type Quantity kY1NOI, k <br /> 1• <br /> O 1'i��� i_.,'-t',s)-it'.I-?i�L )'-t:j 5'11: 13:::. `:3(�:lf(4)7(•1 WAS..t:i:� <br /> 4 <br /> 2. <br /> 70 <br /> R 4 4 <br /> 3. j <br /> jU1. 2 a X01-1 ! � <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> 14.Special Handrng Instructions and Addifwal Infoimaton <br /> � , . " u r r a a r, 3t`Y <br /> �t�>,�..�ir }�i•i i,'ji ?)`.1;'li.� t:•,�.z._ t)::Lt1 '"I:it) �: rf.r�Sl;r:Ci.-,(`.. �- .r <br /> , i?1JI"I-,+jig,7lt.FPA A t.,:JfJE.;.Vit._.:,NON i-- APP Ott?t :°.iA] L :,klirr , <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATfON:I hereby declare that the contents of iNs consignment are fuly and accuratelydeacnbed above by the proper shipping name,and are classified,pac'<aged, <br /> marked and bbeled!oacatded,and are in al respects In proper conditon for Uanspod accabitg to appfcaNe interna6caal and nafonal govetmtenlal regulations.if ezporf sh!pmenl and I am the Primary <br /> Exporter,I comfy Nal the wntents of this ccns�nmenl conform to the terms of the attached EPA Act ah*cd enl of Consent. <br /> I ceitsty 0tat the wasto mbmiza[on statement ldenGfed In 40 CFR 282.27(a)(41 am a large quantity genualor)or(b)(if I am a small quanVy generator)Is true. <br /> Gene at sldfreroes PfinteaTy Naim S!ggature Month Day Year <br /> •-i 18.1infernaWal Sldpmenfs <br /> ❑fmpat to U.S. El Export from U.S. Pod of enUylaxit: <br /> Transpotter srgnalore(for exports only): Data tearing U.S.: <br /> 17.TransporterA nah',edgmenlofReceiptofMaterials <br /> Transporter IPrintedrrypedName Signakue Month Day Year <br /> t P6 yl. o s <br /> Transporter 2 Prin1e0yped Name S:gnalure 1ldrilh Day Year <br /> 18.Qw:scteparicy <br /> 18a.Iksuepancyfr4k ation Space ❑Quantity ❑Type ❑Res!due El Partial Re;ecfson ❑Ful Relecton <br /> Manifest Refetenco Number'. <br /> 18b,Alternate Faciity(or Generator) U.S.EPA 10 Number <br /> I F.Ity's Plane: <br /> w 18c SignahrreofNternateFacitry{or Generator) Month Day Year <br /> �z <br /> S219.Hazafdou 4Ya R h rent Mel ad Codes P.o.,codes(a hazardous waste Ueatment,disposal,and tecychng systems) <br /> M t. A2. <br /> i <br /> 20.Designated Facirl fl?net of Operator:C .cafon of tecelpt of haza materia s coyered by the manifest except as rated• m 1 <br /> Prinledfr me 10 <br /> �j S?gnaWra <br /> Zf <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIR Q} <br />